Related Experiment Video
Updated: Jul 24, 2025
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Utilization outcomes of direct oral anticoagulants in Medicare patients
Prachi Arora1, Maria Muehrcke1, Molly Russell1
1College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
Insights
Apixaban showed the highest adherence among direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). Warfarin had the highest discontinuation rates, while Medicare plans favored rivaroxaban coverage.
Area of Science:
- Pharmacoeconomics and Health Outcomes Research
- Cardiovascular Medicine
- Health Services Research
Background:
- Direct oral anticoagulants (DOACs) are widely prescribed for non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE).
- Understanding patient adherence, persistence, and switching patterns is crucial for optimizing treatment outcomes and managing healthcare costs.
Purpose of the Study:
- To compare adherence, persistence, discontinuation, and switching rates of DOACs (dabigatran, rivaroxaban, apixaban, edoxaban) and warfarin in Medicare patients with NVAF or VTE.
- To analyze the impact of Medicare coverage decisions on drug utilization and patient out-of-pocket costs.
Main Methods:
- Retrospective observational cohort study using Medicare Part D claims data from 2015-2018.
- Identified NVAF and VTE patient cohorts treated with specific anticoagulants between 2016-2017.
- Assessed adherence (PDC), persistence, time to non-persistence, discontinuation, and switching rates over a 365-day follow-up period.
Main Results:
- Apixaban demonstrated the highest adherence (PDC = 76.88%) among DOACs for both NVAF and VTE patients.
- Warfarin exhibited the highest rates of non-persistence and discontinuation.
- Most switches occurred from dabigatran to other DOACs, and from other DOACs to apixaban.
- Despite apixaban's superior utilization outcomes, Medicare plans favored rivaroxaban, resulting in lower patient costs but higher plan expenditures.
Conclusions:
- Apixaban is associated with better adherence and persistence compared to other DOACs and warfarin in Medicare patients.
- Medicare coverage decisions may not align with optimal drug utilization outcomes, as seen with rivaroxaban's favorable plan coverage despite lower patient adherence.
- Coverage decisions for anticoagulants should incorporate adherence, persistence, discontinuation, and switching data to ensure effective and cost-efficient patient care.
Objective:
To compare the adherence, persistence, discontinuation and switching rates of direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE).
Methods:
This was retrospective observational cohort study design. Medicare Part D claims files were used for the study duration (2015-2018). Inclusion-exclusion criteria were applied to identify the NVAF and VTE sample using dabigatran, rivaroxaban, apixaban, edoxaban and warfarin during the identification period (2016-2017). Outcomes of adherence, persistence, time to non-persistence and time to discontinuation were assessed in those who did not switch the index drug in the follow-up period (365 days from the index date). Switching rates were assessed in those who switched the index drug at least once in the aforementioned follow-up period. Descriptive statistics were conducted for all the outcomes, and comparisons were made using t-tests, chi-square, and ANOVA. Logistic regression was conducted to compare the odds of being adherent and the odds of switching in NVAF and VTE patient cohorts.
Results:
Of all the DOACs, patients with NVAF or VTE were most adherent to apixaban (PDC = 76.88). Among all the DOACs, non-persistence and discontinuation rates were highest for warfarin. Majority of the switches were reported from dabigatran to other DOAC and to apixaban from other DOAC. Despite the better utilization outcomes reported for apixaban users, Medicare plans covered rivaroxaban favorably. It was associated with the lowest mean amount paid by the patient (NVAF: $76; VTE: $59), and the highest mean amount paid by the plans (NVAF: $359; VTE: $326).
Conclusion:
Medicare plans need to consider adherence, persistence, discontinuation and switching rates of DOACs to make the coverage decisions.
Related Concept Videos
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:29Venous Thrombosis III: Interprofessional Care
01:20Antiplatelet Drugs: Prostaglandin Synthesis, P2Y12 and Glycoprotein IIb/IIIa Inhibitors
Prostaglandin synthesis inhibitors, exemplified by the widely known aspirin, wield their power by irreversibly acetylating...
01:30Venous Thrombosis IV: Nursing Management
01:25Antihypertensive Drugs: Direct Renin Inhibitors